Provider Demographics
NPI:1346400173
Name:SHAW, DELOY ANTONIO (IDC)
Entity Type:Individual
Prefix:
First Name:DELOY
Middle Name:ANTONIO
Last Name:SHAW
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MWSS 274 2D MAW
Mailing Address - Street 2:PSC BOX 8079
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09509-8107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MWSS 274 2D MAW
Practice Address - Street 2:UNIT 78107
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09509-8107
Practice Address - Country:US
Practice Address - Phone:252-466-4521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman